Clarification regarding billing by CGHS empanelled Hospitals

F No Z/1/2022-DIR(CGHS)-CGHS DEPARTMENT
Govt. of India
Min. of Health & Family Welfare
Department of Health & Family Welfare
Directorate General of CGHS

545-A Nirman Bhawan, New Delhi.
Dated the 10th Nov 2022

OFFICE MEMORANDUM

Subject: Clarification regarding billing by CGHS empanelled Hospitals

With reference to the above subject the undersigned is directed to draw attention to the OM No 2-1/201/CGHS/VC/CGHS(P) dated the 1st August 2013 vide which clarifications were issued regarding admissible and non admissible items.

As per para ( c) of the above referred OM it was clarified that during in-patient treatment of the CGHS beneficiary , the hospital will not ask the beneficiary or his/her attendant to purchase separately the medicines / sundries / equipment or accessories from outside and will provide the treatment within package rate, fixed by the CGHS which includes the cost of all the items.

Under para 2 of the above referred OM it has also been clarified that expenses incurred on medicines, consumables , sundry accessories , etc., which are purchased from outside , based on specific authorization of treating doctor/staff of the concerned hospital will be reimbursable if they are not falling under the list of non-admissible items. In case the empanelled hospital has asked a CGHS beneficiary for purchase of the said item over and above the package rates, reimbursement shall be made to the beneficiary and the amount shall be recovered from the pending bills of hospital.

2. In view of the clarifications already issued by the Government it is once again reiterated and further clarified that the empanelled hospitals shall not prepare two separate bills for the same period of treatment i.e., one separate bill to claim payment from CGHS /Department and another to be paid by the beneficiary. Any violation of these guidelines shall be viewed seriously and suitable action as per the terms and conditions of MOA, including removal from CGHS panel , shall be taken against erring hospital(s).

3. In addition, the undersigned is directed to issue the following other guidelines related to treatment and billing in respect of CGHS beneficiaries:

Prescriptions issued by Specialists of empanelled hospitals in respect of medicines must mention generic name.
Specialists of empanelled hospitals shall not prescribe medicines of equivocal value nor items that come under the category of nutritional substances.
Antibiotic policy (of the hospital) must be followed and care should be taken for judicious use of high end antibiotics including anti-fungal agents. High end anti-biotics including antifungal agents should preferably be used on recommendations of a Committee constituted for the same.
There are prescribed guidelines for use of IV Albumin and they should be adhered to.
Disposable items must be utilized in optimum quantity.
Medicine is a branch of science and it should be practised scientifically only.

Investigations and treatment provided to the patient must be based on the differential diagnosis and provisional diagnosis arrived at on the basis of complaints, history of the patient and clinical examination findings which must be documented.

Investigations which are repeated must add value to the treatment or commensurate with the treatment.

Well established form of therapy should be used. Procedure/ drug on trial should not be used.

lf a new or newer form of drug / procedure is used, it should be specifically indicated for that particular patient because of the decisive superiority over the existing drug / procedure.

4, SUBMISSION OF HOPSITAL BILL – ORDER OF DOCUMENTS

The documents in bill should be arranged as per the following order:

Copy of CGHS Card
Copy of Permission Letter in non-emergencies / beneficiaries upto 75 yrs age
Emergency Certificate — with details
Copy of the Discharge Summary- in detail
Copy of valid NABH/NABL certificate
Hospital Bill for payment — consolidated followed by break-up bill in chronological order
Legible Copy of day to day medical notes signed by treating Doctor and progress chart in chronological order
Copies of investigation in chronological order
Copy of invoice pertaining to Implant along with sticker if any- even if hospital purchased in bulk, copy of invoice relevant to the batch number shall be enclosed.
Any other relevant document

In case documents are not arranged in proper chronological order, the bill may be returned.

5. CGHS scrutinizes the credit bills received in respect of the above items and if , it is considered that there are unjustified use of certain items , they shall be deducted from approved bills. CGHS also reserves the right to take suitable action in case of deviation.

The Additional Directors , CGHS are advised to bring the contents of this letter to the notice of all empanelled HCOs

(Nikhilesh Chandra)
Director, CGHS

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